Sedation FAQ

WHAT DOES “MAC” MEAN?

MAC stands for “Monitored Anesthesia Care”. This term is often used to distinguish from “Moderate Sedation” (previously known as “Conscious Sedation”). While MAC may include giving sedative medications often used for Moderate Sedation, the term MAC denotes that a qualified Anesthesia Provider is involved, focused exclusively on continuous monitoring of the patient, and that that provider is ready to manage any airway/oxygenation issues (breathing problems) or hemodynamic/physiologic issues (such as high or low blood pressure or abnormal heart rhythms). Certified Registered Nurse Anesthetists (CRNA’s) are advanced practice providers who are highly trained to provide MAC services.

By contrast, Moderate Sedation typically involves a medical doctor (MD) taking on a dual role of performing a procedure and supervising a nurse giving the intravenous sedative medications.

WHAT MEDICATIONS ARE USED WITH MAC?

Because the additional clinician giving sedative medications with MAC is dedicated to the patient’s sedation and related safety aspects and is highly trained to handle complications that might arise, a different medication, called propofol, can be used with MAC.

With moderate sedation, fentanyl or meperidine (Demerol) and midazolam (Versed) are the typical medications used. With MAC, propofol is often the primary medication given and is often the only medication needed.

DO ALL PATIENTS RECEIVE MAC?

It is our goal for all patients who receive sedation at Northwest Endoscopy Center to receive MAC via Salish Sedation Services. Unfortunately, due to nationwide anesthesia provider staffing shortages, NW Endoscopy may still be doing some cases with moderate sedation under the direction of our physicians. Cases will be reviewed to determine appropriateness for possible moderate sedation. If an anesthesia provider can be scheduled, the case may be converted to MAC. Your safety is our utmost concern regardless of the method of sedation provided. Our providers are experienced with both forms of medically acceptable sedation for endoscopic procedures. Please reach out to us if you have any concerns regarding sedation.

WHAT ARE THE ADVANTAGES OF MAC?

• Dedicated Anesthesia Provider focused on patient safety during sedation.
• Allows the gastroenterologist/endoscopist doctor to focus on the procedural aspects of each case.
• Allows for more flexibility in scheduling patients, which ultimately translates to more efficient and effective scheduling options for patients.
• Overall higher level of patient satisfaction than Moderate Sedation.
• Propofol medication can be used, with the below advantages:
  • Less nausea/vomiting side effects.
  • Quicker onset and offset, allowing patients to recover and feel better faster after their procedure.
  • Less prone to the “hang-over” feeling or prolonged fatigue symptoms common to other sedative medications.
  • Considered a safe medication, when properly administered and monitored by a qualified Anesthesia Provider.
  • Can be adjusted (titrated) to achieve the desired sedation level individualized for each patient, from those who only want to be lightly asleep to those who wish to be more deeply asleep throughout their procedure.
  • More able to sedate adequately to accomplish procedures that are of longer duration.

WHAT ARE THE RISKS OF SEDATION?

As with any medical procedure, there are associated risks, including with sedation. You will be asked to give your consent for both the procedure and the sedation. Informed consent means that the patient has been made aware of the risks, benefits, and alternatives to doing or not doing the procedure. The Anesthesia Provider and Gastroenterologist involved in your case will meet with you prior, obtain your consent and answer any questions you may have. Your gastroenterologist is also available to you prior to your case for more detailed in-office/telehealth consultation about the procedure, and/or the risks/benefits/alternatives particular to your case. Both the Procedure Consent Forms and Anesthesia Consent Forms are available on our website in multiple languages for your convenience and review prior to arrival.

Please recognize that the consent process is a two-way street; just as you must agree to receive the procedure and sedation, all of the providers involved must feel comfortable taking the risks of proceeding with the plan. If new information arises, you have failed to disclose important health information, proper preparation has not been followed, or your medical condition has changed, there is a risk your procedure will be cancelled, for your own safety.

WHAT ARE MY ALTERNATIVES?

For patients having sedation with procedures at Northwest Endoscopy Center (NWEC), MAC is given to all patients. A select few patients elect to have procedures without any sedation. Please note that it is advisable to discuss the option of an unsedated procedure with a provider prior to your procedure, if interested. We generally recommend being prepared with an escort to take you home afterwards, even if you anticipate having the procedure without sedative medications. Please note that an IV (intravenous access line) will need to be inserted even if no sedation is elected, for patient safety. Unsedated upper endoscopies (EGD) are generally not advised. Colonoscopies can be performed on unsedated patients, but the patient can expect to experience discomfort and/or pain at times. The anesthesia provider will still be present to monitor you during your procedure even if no sedation is given, but there will be no charge from the anesthesia provider unless medications are needed. Moderate sedation is sometimes still given for cases scheduled at the local hospital; however the hospital is likewise moving in the direction of MAC for most endoscopy cases, and costs tend to be overall higher for procedures performed at the hospital.

WHAT IS SALISH SEDATION SERVICES?

Salish Sedation Services is the name of the Anesthesia Provider group that is contracted to provide MAC at Northwest Endoscopy Center. By having a dedicated small group of Anesthesia Providers, these clinicians come to know our workflow and expectations very well, and a high level of care is provided. Because Salish Sedation Services’ Anesthesia Providers operate under their own independent licenses, a separate Anesthesia Consent Form will need to be signed, in addition to the Procedural Consent Form with the gastroenterologist. Related to this desired close oversight of Salish Sedation Services PLLC, some of the physicians of Northwest Gastroenterology have ownership interest.

WILL MY INSURANCE COVER MAC BY SALISH SEDATION SERVICES?

Salish Sedation Services is in-network for most insurance that is accepted at Northwest Endoscopy Center. That means that a contracted rate has been negotiated with your carrier to provide professional sedation services. Your carrier will determine if you have any financial responsibility (co-payment, co-insurance, or deductible) based on your specific plan and benefits. As noted in more detail below, some insurance plans do not consider sedation medically necessary and may deny coverage.

In an effort to contain costs, some insurance carriers deny coverage for MAC saying it is not “medically necessary,” making it difficult to get authorization or pre-authorization for MAC. For those patients for whom we expect insurance may not cover anesthesia services, an Advanced Beneficiary Notice (ABN) is offered whereby we have worked closely with Salish Sedation Services to offer a deeply discounted rate for the sedation services.

Please note that an ABN is used when a service (in this case, MAC) is not covered. If a patient is insured, they must use their insurance plan, subject to any deductible, coinsurance, or copayment. Unfortunately, a patient CANNOT elect to not use their insurance in the situation where the ABN offer is lower than the contracted rate with the insurance carrier, or when the patient is not truly “self-pay.” We too appreciate the complexity (sometimes absurdity) of insurance policies; however, we are obligated to follow the agreed upon terms based on complex contract negotiations with insurance carriers.

If you have questions regarding your specific insurance plan coverage benefits, please contact your insurance carrier directly or your employer’s human resource department. Our own Billing Department can also help answer your questions. Direct questions to Billing at 360-734-1420, option 5.

WHAT BILLS CAN I EXPECT?

Patients can expect to receive as many as four bills for their outpatient endoscopy procedure:

1. Salish Sedation Services – fee for the services provided by the Anesthesia Provider who sedated you and cared for you during the procedure. Direct billing questions to 1-800-222-1442.
2. Northwest Gastroenterology – professional fee from the physician who performed the procedure. A second charge may appear on the same statement, for the histology processing of any tissue specimens taken. Direct questions to Billing at 360-734-1420, option 5.
3. Northwest Endoscopy Center – facility fee from the Ambulatory Surgery Center to cover supplies, medications, equipment, and staffing. Direct questions to Billing at 360-734-1420, option 5.
4. Northwest Pathology – fee from the specially trained pathologist for interpretation/reading of the slides made from any tissue samples during your procedure. Direct questions to 360-201-1676.

WHEN CAN I DRIVE AGAIN?

Although you are expected to be fairly alert after your procedure and upon discharge, studies have still shown impaired driving afterwards. Thus, if you receive any amount of sedative medications, you must have a trusted adult escort to whom we can hand you off after the procedure to drive you home. You may not take a taxi or Uber/Lyft-type service home afterwards, unless you are also in that vehicle with a trusted adult previously known to you. There may be specialty medical transportation services available to you for hire that would qualify; ask a staff member for details in advance. In order to avoid any “driving while impaired” type violations, it is recommended that you not operate a vehicle until the next day, after a good sleep. Failure to follow these instructions, may result in cancellation of your procedure or dismissal from the medical practice.

WHEN CAN I GO TO WORK AGAIN?

Similar to driving, it is recommended that you get a good night’s rest after the procedure, and you should be able to return to work the following day, if you received sedation. Talk to your providers if you have special concerns based on the nature of your work.

WHEN DO I NEED TO STOP EATING/DRINKING BEFORE THE PROCEDURE?

You will received “prep instructions” prior to your procedure, detailing this kind of information and when to arrive for your procedure. In general, you must stop eating any solid foods 8 hours before your procedure and stop all clear liquids 3 hours prior. Clear liquids include water, apple juice, sports drinks etc. (liquids that are somewhat transparent when poured into a glass). Please note that drinks that are thicker (e.g. milk, nectar, smoothies), with pulp or fat in them, do NOT count as clear liquids. Your bowel prep is a clear liquid too, and it must also be stopped 3 hours prior. Water, hard candy, gum and chewing tobacco must also be stopped 3 hours prior as well. If you do not follow these instructions, your case will likely be cancelled. We regret that we typically cannot wait the additional time for you to meet this time threshold, as this would inconvenience subsequently scheduled patients.

WHEN CAN I EAT AGAIN AFTER THE PROCEDURE?

You should feel pretty good after a procedure and be able to eat shortly thereafter, whether at your home or out at a restaurant. As always, it is important to listen to your body and determine how bloated or crampy you feel afterwards. The team caring for you can help answer this for you following the procedure once the details of your particular case are better known.

SPECIAL SITUATIONS SUCH AS BREAST FEEDING OR PREGNANCY:

Please be sure to speak to us in advance if you are pregnant. There are special risks of doing an endoscopy procedure or giving sedation to a pregnant patient that must be carefully considered. Women will be required to provide date of last menstruation, have a pregnancy test at our center, or sign a waiver prior to their procedure, indicating no current/known pregnancy.

If you are breastfeeding, we also encourage you to discuss your breastfeeding plans with your GI provider in advance of a procedure, so you can plan accordingly. Propofol is excreted in breast milk with maximum concentrations for 4-5 hours after administration. The effect of small doses on infants is unknown. According to the American Society for Gastrointestinal Endoscopy (ASGE) 2012 “Guidelines for endoscopy in pregnant and lactating women,” no interruption of breastfeeding is recommended. Some anesthesia providers may err on the side of caution and recommend withholding breastfeeding for up to 24 hours regardless.

Fentanyl is excreted in breast milk, but the concentrations are too low to be significant and fall to undetectable levels by 10 hours. The American Academy of Pediatrics considers fentanyl to be compatible with breastfeeding.

Midazolam is excreted in breast milk. The American Academy of Pediatrics considers the effects on nursing infants to be unknown. Based on limited data, it is advised to withhold nursing for 4 hours after administration.

When withholding nursing, pumping, and discarding is recommended, and parents are advised to plan ahead. Patients are also encouraged to speak to their child’s healthcare provider(s) or pediatricians with any additional concerns.